Form Arc 2 - Redetermination - Statement Of Facts Supporting Eligibility For The Approved Relative Caregiver (Arc) Funding Option Program
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1STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REDETERMINATION: STATEMENT OF FACTS SUPPORTING ELIGIBILITY FOR
COUNTY USE ONLY
THE APPROVED RELATIVE CAREGIVER (ARC) FUNDING OPTION PROGRAM
COUNTY AND AGENCY
INSTRUCTIONS: Please complete in ink all of the questions to the left of the heavy black line.
If you need more space, attach another sheet of paper. Fill out this form for each participating
DATE RECEIVED
child/youth. (This form, the ARC 2, is for redetermination. To apply for the ARC Program,
complete the ARC 1 form.)
CASE NAME
1. Approved Relative Caregiver’s Name
Phone
(
)
CASE NUMBER
Birthdate (Month, Day, Year)
Social Security Number
WORKER NAME AND NUMBER
2. Child/Youth’s Name (First, Middle, Last)
Gender
Male
Female
Address
Birthdate (Month, Day, Year)
Birthplace (City, State, Country)
Social Security Number
Relationship to Approved Relative Caregiver
3. Does the child/youth still live with you?
YES
NO
4. Does the child/youth have, or expect to
5. Did the child’s/youth’s income change or is
Verification of property:
have, any new property?
it expected to change?
_____________________________
YES
NO
YES
NO
Verification of income:
If “YES,” list below:
If “YES,” please list below:
_____________________________
PROPERTY TYPE
VALUE
TYPE
AMOUNT
WHEN
Verification provided
Exempt
Will this income continue?
YES
NO
Please explain:
CERTIFICATION
I understand that:
• I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility is fraud
and that I may be subject to penalties under state and federal law if I provide false or untrue information. Fraud can cause a criminal
case to be filed against me and/or I may be barred for a period of time (or life) from getting ARC benefits.
• I understand that Social Security Numbers or Immigration Status for household members applying for benefits may be shared with the
appropriate government agencies as required by federal law.
I declare under penalty of perjury under the laws of the State of California that the information contained on this Statement of
Facts is true, correct, and complete to the best of my knowledge.
SIGNATURE OF APPROVED RELATIVE CAREGIVER
DATE
COUNTY USE ONLY
INELIGIBLE AT REDETERMINATION (Reason)
ELIGIBLE AT REDETERMINATION
Eligibility Redetermination Date:
CalWORKs Eligible
ARC-only Eligible
(Explain any eligibility changes, such as no longer CalWORKs eligible but still ARC eligible.)
Date
Signature of County Worker
Signature of Supervisor
Date
ARC 2 (11/16) REQUIRED FORM – NO SUBSTITUTE PERMITTED
PAGE 1 OF 1
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